Roberto Bristot

High-dose radiation-induced meningiomas

BACKGROUND Numerous neoplasms within the CNS have been reported as radiogenic in origin; radiation-induced meningiomas are at least five times more numerous than gliomas or sarcomas in the world literature. METHODS The authors review 10 cases of cerebral meningiomas following high-dose radiotherapy in patients operated for neoplasm of the nervous system. The pathologic and clinical aspects of this unusual complication are analyzed in all cases in the world literature. RESULTS There is a female predominance (F-M ratio: 3:2) and the patients are young (mean age: 33.1 years; median: 29 years). The average latency period is 14.4 years (range: 9-21 years). The first disease is acute lymphocytic leukemia (ALL) in 40% of cases. Radiation induced meningiomas are atypical in four cases. Recurrence was observed in one case without malignant transformation. CONCLUSION High-dose radiation-induced meningiomas have the following characteristics: (1) children appear particularly sensitive to the development of this tumor; (2) there is a female predominance, otherwise than is observed in low-dose meningioma; (3) these tumors present a peak frequency in the third decade of life; and (4) frequently, these tumors are atypical and recur. Finally, it is essential that every new case be reported to throw light on this particular pathologic correlation with its many grey areas.

Surgical treatment of thoracic disc herniation: A reappraisal of Larson's lateral extracavitary approach

Twenty patients with thoracic disc herniations underwent removal of the transverse process, articular facet, pedicle, and rib--a procedure described by Larson as the lateral extracavitary approach. Eleven patients presented with myelopathy: five mild, nine moderate, and four severe. Fifteen patients showed significant neurologic improvement after the operation and five patients none. Postoperative follow-up ranged from 1 to 8 years. The pros and cons of each of the surgical approaches to this type of lesion are considered with reference to the published data.

Epileptic seizures in intracerebral hemorrhage: a clinical and prognostic study of 55 cases

Fifty-five cases of epileptic seizures associated with spontaneous intracerebral hemorrhage are reported. Seizures appeared as the first symptom in 23 patients, early (within two weeks after HI) in 18 and late (later than 2 weeks after HI) in 14. From the analysis of the observed cases we noticed that: 1) partial seizures were most frequent type (63%). These appeared mainly in cases with lobar hemorrhage above all; 2) development chronic epilepsy occurred frequently in the case of patients affected by late seizures. We compare our data with those reported in literature in order to highlight main factors which affect the onset and development of seizures associated with spontaneous intracerebral haemorrhage.

Cavernoma of the cavernous sinus: Case report

BACKGROUND The authors report a case of extra-axial cerebral cavernoma localized at the level of the cavernous sinus. This pathology is extremely rare, therefore, differential diagnosis with tumors such as meningioma is often difficult. During recent years, surgical indications for these lesions, congenital and rarely hereditary, have become more definite due to the considerable progress made in neuroradiologic and microsurgic techniques as well as better anatomic knowledge of this region. METHODS This 49-year-old man was admitted with a 1-year history of diplopia. Cranial computed tomography (CT) scan with contrast medium, performed prior to admission, showed an expansive lesion at the level of the right cavernous sinus. Preoperative neuroradiologic diagnosis, after cerebral magnetic resonance imaging (MRI) with gadolinium enhancement and cerebral panangiography, was probable cavernoma. The lesion was totally removed via a fronto-orbito-temporo-zygomatic craniotomy. RESULTS Postoperatively, the patient had a right oculomotor nerve palsy. This spontaneously resolved 8 months after surgery; diplopia also completely disappeared. Early postoperative control MRI scans with gadolinium on the 2nd postoperative day and 3 months after operation confirmed total removal of the lesion. CONCLUSIONS The clinical onset and neuroradiologic aspect of these lesions and the fact that they rarely involve the cavernous sinus, may sometimes make preoperative diagnosis of cavernous sinus cavernoma difficult. Nevertheless, given the routine use of microsurgical techniques and improved anatomic knowledge of this delicate region, the treatment of choice is surgery. However, when doubts exist regarding achievement of total removal, radiosurgery is still a valid therapeutic tool.

Extradural spinal cavernous angiomas: report of seven cases

The authors describe seven cases of extradural spinal cavernous angioma. Although cavernoma itself is not rare, the extradural spinal localization is uncommon and makes preoperative differential diagnosis difficult. Routine MRI investigation has aided neurosurgeons in evaluating the true incidence of these vascular malformations, which was understimated in the past. The data published so far have not entirely clarified the treatment of choice for these lesions. Considering their rarity in this site, their presenting symptoms and the difficulties involved in neuroradiological diagnosis, the authors discuss the role of surgery as the principal form of treatment and review the relevant literature. Seven patients (4 male, 3 female) were admitted to our Institute of Neurosurgery between 1992 and 2004, with a 5–6 month history (range=2–365 days) of low back pain or radicular pain, sometimes associated with paresthesia. All patients had a CT scan, as well as MRI with gadolinium when possible, which detected an extradural roundish lesion: differential diagnosis was very difficult, especially between neurinoma and cavernoma. Treatment was always surgical and resection of the lesion radical. Postoperatively, all patients presented complete regression of clinical symptoms. In all cases histological diagnosis was cavernous angioma. Postoperative MRI with gadolinium or CT scan with IV contrast, performed before discharge, confirmed radical removal of the vascular malformation in all cases. Our experience confirms that surgery should be the treatment of choice for these lesions, in view of both their tendency to bleed and their straightforward surgical removal.

Post-radiation gliomas.

Aims and background Radiotherapy is important in the treatment of neoplasm of the central nervous system, but various side effects, particularly neoplastic, have been described. Recently, post-radiation gliomas have been reported. Methods The authors review 88 cases of cerebral glioma following radiotherapy in patients operated for neoplasms of the nervous system, including 6 personal cases of post-radiation gliomas treated in the Neurosurgical Division of the Department of Neurological Sciences, “La Sapienza” University, Rome. The criteria used to define this unusual pathologic association are discussed. Results There was a male predominance. Post-radiation gliomas were particularly malignant, the average dose was 33 Gy, and average free latency was 9.6 years. The first disease was most frequently acute lymphatic leukemia. Conclusions Post-radiation gliomas have particular features but do not present a histologic or clinical behavior different from analogous spontaneous gliomas. The fact that 88 cases have been reported in recent years suggests that a thorough biological, clinical studies be carried out on this association.

Congenital torticollis in association with craniosynostosis

Abstract The incidence of congenital torticollis in association with plagiocephaly is 1 in 300 newborns, with the torticollis resulting from pathologically sustained contraction of the sternocleidomastoid. Such conditions as facial asymmetries, craniovertebral anomalies, cervical hemivertebra, and mono- or polydysostoses may also be associated with torticollis diagnosed during the neonatal period. With particular reference to synostotic (coronal and/or lambdoidal) plagiocephaly, a clear distinction is made in this paper between posterior neurocranial flattening secondary to the sustained rotation of the skull resulting from torticollis and that seen in synostotic plagiocephaly. The rarity of torticollis with sustained contraction of the sternocleidomastoid muscle relative to the frequency of occipital-parietal flattening in newborn kept in the supine position has not been discussed in the literature and is therefore of clinical importance. In light of the fact that the prognosis and, consequently, the treatment plan vary directly with the presence or absence of synostoses, clinical evaluation also includes cephalometrics, plain skull X-rays, and CT imaging. If the torticollis is associated with neurocranial deformity but synostosis is absent, cervical traction and physiotherapy resolve the symptoms. When, however, the clinical picture is complicated by synostotic plagiocephaly, corrective surgery is necessary, though cervical traction and physiotherapy are essential to provide early and complete cure of the torticollis.

Intracranial actinomycosis in juvenile patients: Case report and review of the literature

Abstract A case of actinomycotic brain infection in a juvenile patient is described. Cases of actinomycosis affecting the head and neck are rare, particularly in juvenile patients. In this case complete resolution of the infection was achieved by means of surgical treatment and prolonged antibiotic therapy. The authors emphasize the importance of a combined approach for treatment of this unusual brain infection and stress the difficulties involved in the diagnosis of this pathology.

Spontaneous cerebellar haemorrhages in childhood

Spontaneous cerebellar haemorrhage is very rare in children and is often associated with blood diseases such as haemophilia A or acute lymphatic leukaemia. During 1995, two paediatric patients with spontaneous cerebellar haemorrhage underwent surgical treatment in the Neurotraumatology Division of “La Sapienza” University hospital in Rome. The authors discuss this unusual pathology with particular regard to the age of the patients described.

Malignant supratentorial astrocytomas of late childhood Our experience with 25 cases

Abstract The authors present 25 patients ranging in age from 8 to 16 years who had malignant supratentorial astrocytomas. This type of lesion represents one of the most important and statistically significant causes of morbidity and mortality in late childhood. Compared to adult malignant supratentorial astrocytomas, these lesions seem to show a better survival rate. The reason is unknown. The authors present their experience regarding the importance of radical removal and histology for a better prognosis.